Golfer’s Elbow

Medial epicondylopathy, which is also known as golfer’s elbow, causes pain on the medial side
of the elbow and is aggravated with resisted wrist flexion and forearm pronation. It is caused by
the overload to the flexor-pronator tendon that attaches to the medial epicondyle of the
humerus. The overload tends to occur with repetitive wrist flexion and forearm pronation and
results in microtears in the flexor-pronator tendon. This is known as a tendinopathy and causes
degenerative changes in the tendon and therefore the collagen fibres within the tendon become
abnormally arranged (Khan et al, 2000).

Symptoms of Golfer’s Elbow

The most common symptoms of Golfer’s elbow are:

• Pain and tenderness on the medial side of the elbow, at the medial epicondyle and common flexor tendon. Pain may refer down the medial side of the forearm and into the hands.
• Pain aggravated by wrist flexion and pronation. 
• Stiffness in the elbow.
• Weakness in the hand and wrist.

Causes of Golfer’s Elbow

Medial epicondylopathy (Golfer’s Elbow) occurs when an excess or overload of stress to the flexor-pronator tendon occurs. 

This may be due to:

• Improper technique with racket sports and using a racket that’s got too small grip or too heavy.
• Improper throwing technique during sports.
• During weight lifting – flexing the wrists during pull ups or bicep curls, will overload the tendon.
• Forceful and repetitive twisting and wrist flexion during work – such as a plumber or construction worker.

The injury may occur after a single traumatic event causing damage to the tendons.

Those diagnosed with type 2 diabetes are more likely to develop medial epicondylopathy.  Smokers and ex-smokers have also been associated with developing the condition (Shiri et al, 2006).

Anatomy of the Elbow joint

The muscles that insert into the medial epicondyle of the humerus are the following:

• Pronator teres
• Flexor carpi radialis (FCR)
• Flexor carpi ulnaris (FCU) 
• Palmaris longus
• Flexor digitorum superficialis (FDS)

The musculotendinous origin of the FCR and pronator teres is where medial epicondylopathy most commonly occurs. The pronator teres muscle flexes the elbow and pronates the forearm. The FCR performs flexion of the wrist and hand, radial deviation of the wrist and pronation of the forearm. It also plays a role as a dynamic stabilizer of the wrist.

How is Golfer’s Elbow diagnosed?

At your physiotherapy appointment, the clinician will take a thorough history and perform a series of tests on the elbow to make the diagnosis and assess potential factors that may have led to your injury. At Oxford Circus Physiotherapy we also use diagnostic ultrasound to image the tendon attachment and joint to check for tears of the tendon or swelling in the joint.

Treatment

Physiotherapy treatment may include:

• Advice on how to reduce pain and symptoms with activity modifications and techniques to unload the tendon temporarily.
• A personalised progressive strengthening and loading program to gradually increase the load capacity of the tendon.
• A gradual phased return plan to normal activities and sport.
• Ultrasound-guided Dry Needling

Extracorporeal Shockwave Treatment

Extracorporeal shockwave therapy (ESWT) is an effective non-invasive treatment for tendinopathies (Dedes et al, 2018) – including medial epicondylopathy (Lee et al, 2012). It works by creating repetitive acoustic waves into the injured tendon and creates microtrauma, which then stimulates the healing process.  At least 3 sessions would be required and ideally in consecutive weeks to gain the optimum benefit from treatment.

Injection therapy for Golfers Elbow

Ultrasound-guided injection therapy for the treatment of Golfer’s elbow can be controversial. We prefer Ultrasound guided Dry Needling or Shockwave for the treatment of this stubborn condition.

Certain treatments may involve dry needling  and then injecting PRP or Hyaluronic acid. Injection treatments that we perform at Oxford Circus Physiotherapy are:

• PRP Injection
• Hyaluronic Acid Injection
• In cases where other treatments are contraindicated and pain is a significant limiting factor, then an ultrasound-guided steroid injection with local anaesthetic can be considered. Research shows this gives the poorest long term outcome in treatments around the elbow but for some people this may be their only option (Tang et al 2020, Inklebarger & Clarke 2015, Hsieh et al 2018) and is only good to relieve pain in the short term.